Gap Payment Rules in NZ Health Insurance
When a provider's charges exceed what the insurer pays, the member pays the 'gap'. NZ insurers use different models — affiliated/preferred provider networks, percentage co-pays, 'reasonable charges' caps. This page lists each insurer's gap rules verbatim.
Source: each insurer's current policy wording PDF (linked inline). Last refreshed 2026-05-16.
Accuro
KidSmart
Wording effective 2026-05-16 · extraction confidence inferred ·
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We will pay up to the Reasonable charges for any covered procedure or treatment, up to the specified benefit limit (whichever is less). If a provider charges above our Reasonable charges, the policyholder must pay the difference directly to the healthcare provider, regardless of the benefit's maximum limit. We will not pay or reimburse any costs exceeding 100% of actual costs incurred. Any refunds, subsidies or entitlements from other sources (ACC, another health insurer, government-funded agency, Work and Income, or employer) must be claimed first, and we deduct those amounts before assessing the remainder. We do not cover any excess applicable under another insurance plan.
SmartCare
Wording effective 2026-05-16 · extraction confidence inferred ·
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UniMed covers Reasonable charges, defined as the cost for a procedure or medical treatment judged to be reasonable and within a range of cost charged for the same procedure under similar circumstances. If a provider charges above Reasonable charges, UniMed may ask for further information or recommend an alternative provider. If the member chooses to proceed at the higher cost, the member must pay the difference between the amount approved and the actual cost, regardless of the benefit's maximum limit, directly to the healthcare provider. UniMed will not pay more than 100% of actual costs incurred. Any refunds, subsidies, or entitlements from another source (including ACC, another health insurer, government-funded agency, Work and Income, or employer) must be claimed first and will be deducted from the total before UniMed assesses the remaining amount. UniMed does not cover excess applicable for another insurance plan.
SmartCare+
Wording effective 2026-05-16 · extraction confidence inferred ·
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UniMed pays up to the Reasonable charges for a procedure or medical treatment, up to the specified benefit limit. If the cost for a procedure or medical treatment is above what UniMed judges to be a Reasonable charge, the member may be asked for further information or recommended an alternative. If the member chooses to proceed with a provider charging above the Reasonable charge, the member must pay the difference between the amount approved and the actual cost, regardless of the benefit's maximum limit. This extra amount must be paid directly to the healthcare provider. If a procedure cost exceeds the benefit maximum limit, the exceeded amount cannot be paid and is the member's responsibility. UniMed does not cover excess applicable under another insurance plan. Members must also claim any other refunds, subsidies, or entitlements (e.g. ACC, another insurer, government-funded agency) first, and UniMed deducts any such reimbursement from the total before assessing the claim.
SmartStay
Wording effective 2026-05-16 · extraction confidence inferred ·
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UniMed pays up to the Reasonable charges for a procedure or medical treatment, or up to the relevant benefit limit, whichever is less. If the actual cost exceeds the Reasonable charge or benefit limit, the member must pay the difference directly to the healthcare provider. If a procedure has costs above what UniMed judges to be Reasonable charges, UniMed may ask for further information or recommend an alternative; if the member proceeds, they pay the excess cost. Prior approval letters will clearly state the maximum amount UniMed will cover and any excess applicable. UniMed will not reimburse or pay more than 100% of actual costs incurred; any amounts covered by ACC, another insurer, or government-funded agencies are deducted before UniMed assesses its portion. UniMed does not cover excess applicable under another insurance plan.
StaffCare
Wording effective 2026-05-16 · extraction confidence verified ·
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We cover Reasonable charges, defined as the cost for a procedure or medical treatment judged to be reasonable and within a range of cost charged for the same procedure under similar circumstances. If the cost exceeds Reasonable charges or the benefit limit, the member must pay the difference directly to the healthcare provider. The insurer will not reimburse any amount exceeding 100% of actual costs incurred. Members must first claim any other refunds, subsidies, or entitlements (including from ACC, another insurer, or government-funded agency), and the insurer will deduct those amounts before assessing the claim. The insurer does not cover an excess applicable under another insurance plan.
StaffCare+
Wording effective 2026-05-16 · extraction confidence inferred ·
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UniMed pays up to the Reasonable charges for any covered procedure or medical treatment, up to the specified benefit limit. If the cost for a procedure exceeds what UniMed judges to be a Reasonable charge, the member must pay the difference between the amount approved and the actual cost directly to the healthcare provider, regardless of the benefit's maximum limit. If the cost exceeds the benefit maximum limit, the excess amount is also the member's responsibility. UniMed will not pay or reimburse any costs that amount to more than 100% of actual costs incurred; any reimbursements from ACC, another health insurer, a government-funded agency, Work and Income, or the employer are deducted before assessing the remaining amount. UniMed does not cover an excess applicable under another insurance plan. The applicable excess (per person, per policy year) is deducted from any payment made to the member or provider, and the member is responsible for paying the excess amount directly to the health service provider.
AIA
AIA Private Health
Wording effective 2026-05-16 · extraction confidence verified ·
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AIA will pay the health service provider directly upon receipt of the invoice or statement up to the maximum cover. The excess and any costs that are not covered (including costs exceeding the maximum cover) must be paid directly by the policy owner to the health service provider. AIA pays only up to the reasonable charges; if the proposed cost exceeds reasonable charges, the policy owner is responsible for the difference regardless of the maximum cover. If treatment is provided by an AIA Healthcare Partnership Programme provider, no prior approval or claims information is needed from the policy owner — the provider bills AIA directly and advises the policy owner of any costs they must pay (e.g. excess, costs not covered, or costs exceeding maximum cover). For treatment outside Australia under the Voluntary Treatment Overseas benefit, AIA pays 85% of the reasonable charges.
nib
Easy Health
Wording effective 2024-09-20 · extraction confidence inferred ·
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If you choose a recognised provider that is part of the First Choice Network, nib covers 100% of eligible costs up to the benefit limit, less any excess. If you choose a recognised provider that is not part of the First Choice Network, a gap payment may apply — the gap payment is the difference between what the provider charges and the Efficient Market Price (the maximum nib will pay for a service by a non-First Choice provider). The Efficient Market Price is determined based on what healthcare providers charge, nib's claims data, and nib's experience with New Zealand's health market. If a pre-approval was obtained, the Efficient Market Price at the pre-approval date applies; if not, the Efficient Market Price at the treatment date applies. The excess (chosen by the policyowner) applies once per insured person per policy year for any accepted claim and must be paid directly to the recognised provider along with any gap payments.
Ultimate Health
Wording effective 2025-11-24 · extraction confidence inferred ·
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The policy pays 80% or 100% of eligible costs depending on the benefit and whether the diagnostic investigation is listed on the Diagnostics Schedule. For benefits paying 80%, the insured person bears the remaining 20% co-payment. For benefits listed on the Diagnostics Schedule, 100% of eligible costs are paid up to the available benefit limit. The Specialist Option pays 80% of eligible costs for specialist consultations and diagnostic tests. No explicit gap payment arrangement between nib and providers (such as a no-gap or known-gap scheme) is described in this document.
Ultimate Health Max
Wording effective 2024-02-01 · extraction confidence verified ·
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The policy pays 100% of eligible costs up to the available benefit limit for Base Cover and most Options (Specialist Option, Non-PHARMAC Plus Option, GP Option). The Dental, Optical, and Therapeutic Option pays 80% of eligible costs up to the available benefit limit. The Medical Tourism Benefit pays a maximum of 75% of the usual, customary and reasonable charges that would have been payable in New Zealand. The Cover in Australia Benefit and Delayed Treatment Benefit pay up to the usual, customary and reasonable charges that would have been payable in New Zealand, up to the overall benefit limit. Payments are made in New Zealand Dollars to the selected New Zealand bank account of the policyowner or insured person and are not paid directly to the health service provider for overseas treatment benefits.
Southern Cross
KiwiCare
Wording effective 2026-04-01 · extraction confidence verified ·
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We'll cover up to 80% of the actual charges incurred for eligible healthcare services, up to the relevant policy limits. The policyholder is responsible for paying the remaining 20% co-payment (and any excess) directly to the health services provider. When using an Affiliated Provider contracted for the healthcare service, Southern Cross will cover 80% of the charges incurred up to policy limits unless Southern Cross or the Affiliated Provider advise otherwise. If actual charges exceed policy limits, the policyholder is responsible for paying the excess amount directly to the health services provider.
RegularCare
Wording effective 2026-04-01 · extraction confidence verified ·
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Southern Cross covers 80% of actual charges incurred for eligible healthcare services up to policy limits, unless the insurer or Affiliated Provider specifies otherwise. The member is responsible for paying the remaining 20% co-payment (the gap) plus any excess directly to the health services provider. When using an Affiliated Provider contracted for a service, Southern Cross covers 80% of charges up to relevant policy limits unless otherwise advised. Members must also pay any amount exceeding policy limits directly to the provider. If another insurer or person is liable to contribute, the amount covered by Southern Cross is reduced by any such payment.
UltraCare
Wording effective 2026-04-01 · extraction confidence inferred ·
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When using an Affiliated Provider contracted for a healthcare service, Southern Cross covers 100% of the actual charges incurred for eligible healthcare services up to relevant policy limits, unless Southern Cross or the Affiliated Provider advise otherwise — no gap payment applies in this case. For non-Affiliated Providers, cover is limited to reasonable charges as determined by Southern Cross; the policyholder is responsible for paying any amount exceeding reasonable charges directly to the health services provider. The policyholder is also responsible for any amount exceeding policy limits. If a healthcare service is assessed under actual charges (rather than reasonable charges), the policyholder pays any amount above the policy limit.
Wellbeing Modules
Wording effective 2026-04-01 · extraction confidence low ·
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Not on file for this product.
Wellbeing One
Wording effective 2026-04-01 · extraction confidence inferred ·
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Where Southern Cross covers 100% of actual charges (typically when an Affiliated Provider is used and unless otherwise advised), no gap applies to the insured. Where reasonable charges apply (typically for non-Affiliated Providers), the insured is responsible for paying any amount exceeding the reasonable charges directly to the health services provider. The insured is also responsible for paying any amount exceeding the policy limits and for paying any applicable excess directly to the health services provider.
Wellbeing Two
Wording effective 2026-04-01 · extraction confidence inferred ·
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Where a healthcare service is performed by an Affiliated Provider, Southern Cross covers 100% of the actual charges incurred unless Southern Cross or the Affiliated Provider advises otherwise — in this case there is no gap for the member. Where Southern Cross covers the reasonable charges (typically when a non-Affiliated Provider is used), the member is responsible for paying any amount exceeding the reasonable charges directly to the health services provider. The member is also responsible for paying any amount exceeding the policy limits, and for paying any excess, directly to the health services provider.
UniMed
Health Positive
Wording effective 2025-08-01 · extraction confidence inferred ·
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Not on file for this product.
Source: https://www.unimed.co.nz/assets/PlansAndDocs/Health-Plans/Health_Positive_Plan.pdf
Hospital Select
Wording effective 2025-08-01 · extraction confidence low ·
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Benefits in all sections refund 100% of the Reasonable Charges limited to the benefit maximums for any admission (Private Hospitalisation Surgical Benefits section). Other sections refund 100% of actual medical costs to the specified maximums. The policy does not describe a formal 'gap payment' scheme between insurer and provider beyond these reimbursement structures.
Source: https://www.unimed.co.nz/assets/PlansAndDocs/Health-Plans/Hospital_Select_Plus_Modules_Plan.pdf
ParentStay
Wording effective 2025-10-01 · extraction confidence inferred ·
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UniMed will pay the cost for a medical treatment or procedure covered under the policy up to the relevant benefit limit or the reasonable charge for the medical treatment or procedure, whichever is less. If the cost exceeds the benefit limit or reasonable charges, the extra cost is the member's responsibility and cannot be claimed under another benefit or policy. Members must claim any other refunds, subsidies, or entitlements available from another source first (including ACC, another insurer, or government-funded scheme). If those sources only partially cover costs, UniMed may pay the difference up to the amount entitled under the Health Plan, where legally permitted. UniMed does not provide cover for any excess that applies under another insurance policy or Health Plan. The policy provides limited coverage for expenses incurred in the private health system.
Source: https://www.unimed.co.nz/assets/PlansAndDocs/Health-Plans/ParentStay-Health-Plan-2025.pdf
UniCare Advantage
Wording effective 2025-08-01 · extraction confidence low ·
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Payments under the Private Hospitalisation Surgical Benefits section are limited to 80% of the Reasonable charges of the procedure up to the per admission limit stated. All benefit sections from the Public Hospital Benefits section forward refund 80% of actual medical costs to the specified maximums. The General Medical Expenses section also refunds 80% of actual medical costs to the specified maximums. All benefits are inclusive of GST charged by healthcare providers.
Source: https://www.unimed.co.nz/assets/PlansAndDocs/Health-Plans/UniCare_Advantage_Plan.pdf
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